August 1, 2017

BehindTheMedspeak: How would you feel if your doctor started crying in your presence?

Turns out both doctors and patients have sharply conflicting opinions about whether such behavior is appropriate, desirable or out of bounds.

A young doctor sat down with a terminal lung cancer patient and her husband to discuss the woman’s gloomy prognosis. The patient began to cry. Then the doctor did, too.

The scene was undoubtedly moving. But should physicians display this much emotion at the bedside?

For years, medical schools and residency training programs studiously avoided the topic of emotions. Doctors learned the nuts and bolts of cancer and other serious diseases. Yet when it came time to reveal grim diagnoses, they were largely on their own.

These days, all medical schools have some type of education in topics like the physician-patient relationship and breaking bad news. But knowing how to respond to a personal wave of stress or sadness remains a major challenge. Is crying O.K.? How about hugging a patient who starts to cry?

One physician who cautions against excess emotions is Dr. Hiram S. Cody III, acting chief of the breast cancer service at Memorial Sloan-Kettering Cancer Center. Although Dr. Cody emphasizes the need for doctors "to understand, to sympathize, to empathize and to reassure," he says his job "is not to be emotional and/or cry with my patients."

There are two reasons for this stance, Dr. Cody tells young physicians on rounds: It is not therapeutic for the patient, and it will cause "emotional burnout" in the doctor.

These beliefs are shared by many other physicians, but some new data suggest that crying in a medical setting is common among young doctors. At a recent meeting of the Society of General Internal Medicine, Dr. Anthony D. Sung of Harvard Medical School and colleagues reported that 69% of medical students and 74% of interns said they had cried at least once. As might be expected, more than twice as many women cried as men.

In some instances on the wards, the emotions just flow. For example, in the 1988 PBS documentary "Can We Make a Better Doctor?" a Harvard medical student, Jane Liebschutz, sees her patient unexpectedly die during a cardiac bypass operation. She suddenly bursts into tears and wanders away from her colleagues until the chief surgeon, who has witnessed what happened, assures her that her response was natural.

Other physicians may choose to place themselves in emotional situations. Dr. May Hua, an anesthesiology resident at Columbia University Medical Center, recently told me that during her internship, her supervising resident, Dr. Benita Burke, skipped lunch to spend extra time with her cancer patients. They dubbed this time "mental health rounds," during which they could address issues that were not strictly medical. Many times, Dr. Burke would wind up in tears or giving an embrace.

"I think patients adored Benita," Dr. Hua said, "both as their doctor and as their friend."

But even as she admired her colleague, Dr. Hua realized that such public emotion was not for her. "I knew this was something I couldn't do, because I needed to have a level of detachment to these people."

I understood exactly what Dr. Hua meant. Whether because of my personality or my being a man, I, too, have never cried in front of a patient.

Dr. Burke says she believes that her crying stems from being "very involved" in her cases, which leads her to "take everything to heart." In the case of the lung cancer patient, Dr. Burke had been the first physician to inform her that further aggressive treatment was unlikely to help. In other words, the patient was dying.

Dr. Burke said she realized that this level of involvement was uncommon but believed that she could not be any other kind of doctor. "I've always been a very emotional person at baseline," she said.

Dr. Sung's study concludes with a call for senior doctors to acknowledge and discuss openly the apparent high rates of crying among medical trainees.

Yet while health professionals — not only physicians but also nurses and social workers — may debate among themselves the propriety of emotional displays, what probably matters most is what patients think. Just as different doctors respond differently to sad situations, so do patients and their families. While some might appreciate physical contact or tears, others find such displays to be too "touchy-feely."

Cancer patients may encounter such situations more than most. One breast cancer survivor, Sharon Rapoport, of Roanoke, Va., said she greatly admired physicians like Dr. Cody, who may appear reserved but communicate their concern through their actions.

But Ms. Rapoport also said she had an extra appreciation for doctors who felt comfortable with outward displays of emotion. "If that means tears," she said, "bring them on."

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Back in the last century when I was an anesthesiology resident at UCLA one of my fellow residents, during a preoperative visit with a patient, got down on his knees at the patient's bedside to pray for him.

He was fired the next day.

A few weeks later he joined the residency program across town at Los Angeles County-University of Southern California Medical Center, where things were so bad his indiscretion was either overlooked or disregarded.

Comments

Reminded me of Paul Bloom's "Against Empathy: The Case for Rational Compassion." They talk about doctor/patient relationship around 9:37 minutes into the interview.http://www.wpr.org/listen/1039026

Posted by: Bubbub | Aug 2, 2017 12:24:13 AM

This was nice to read. Due to a congenital heart defect I have been to the doctors more times than I can count. I had surgery when I was just a baby, and I believed everything was well until I at 17, during what I had believed to be a control visit, learned that I needed a second surgery, and will keep needing surgeries every every 10-20 years for the rest of my life. The news came as a shock for me, and not until now, 5 years later, have I stopped for a second to consider how it must be to deliver such information.